Anchor subperiosteal forehead lift: from open to endoscopic.
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Endoscopy↗
Biomedical subjects
O M Ramirez
Publications and source records attributed to O M Ramirez.
Abdominoplasty and abdominal wall rehabilitation: a comprehensive approach.
Standard abdominoplasty techniques involve a low horizontal or W skin excision, muscle plication, and umbilical transposition. Newer techniques include suction-assisted lipectomy, the use of high lateral tension with fascial suspension, and external oblique muscle advancement. The author has modified these traditional procedures and added new techniques to improve the aesthetic and functional results of the abdominoplasty procedure. This modification provides a comprehensive approach to abdominal wall aesthetic improvement and rehabilitation. The comprehensive approach described includes four components: the "U-M dermolipectomy," "V umbilicoplasty," the rectus abdominis "myofascial release," and suction-assisted lipectomy. The patient is marked while standing for areas of suction lipectomy and undermining. The lower incision is designed as an open U with the lateral limbs placed inside the bikini line. The upper incision is a lazy M with the higher peaks located at the level of the flanks. Subcutaneous hydration is achieved to perform suction along the flanks, waistline, and iliac areas. Gentle suction of the flaps is also performed. The umbilicus is cored out in a heart shape. The flaps within the U-M marks are excised, and the undermining is performed to the xiphoid and costal margins. The rectus diastasis is marked, and the anterior rectus fascia is incised at the junction of the medial third with the central third of the width of the rectus sheath. Horizontal figure-eight plication sutures by using the lateral fascial edge enable easier infolding of the central tissue. The new recipient of the umbilicus is made by an incision in a V shape on the abdominal flap. The umbilicus is telescoped, and the triangular flap of the abdomen is sutured to the triangular defect of the umbilicus. Skin flap fixation to the umbilicus relieves tension in the lower portion of the flap. The upper skin flap, which is cut in an M manner, provides lateral tension and matches the length of the lower flap. A standard fascial suspension is used and closure is performed in layers. The techniques described here are intertwined procedures. Each facilitates the accomplishment of the other procedure, and they complement each other. They all attain the 12 objectives of the abdominoplasty described. These combined techniques have been used in 104 patients in a period of 11 years. Complications were minimal and easily manageable, except for one patient who required excision of a pseudobursa and retightening of the lower quadrants of the abdominal wall musculature to correct extreme lordosis. A comprehensive approach for the treatment of complex abdominal wall aesthetic and functional defects is presented. These require thoughtful integration of the four components mentioned. This approach has allowed predictable, reproducible, and aesthetically pleasing results.
Abdominal Muscles↗
Blood supply to the gluteus maximus flap.
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Buttocks↗
Mandibular matrix implant system: a method to restore skeletal support to the lower face.
Disharmony between the skeletal support and the softtissue envelope is a common cause of aesthetic concerns regarding the lower face. A loss of volume or a genetically small mandible affects the aesthetics and function of the mouth, chin, and neck. Because of the limitations of correcting such problems with current implants made of silicone or porous polyethylene, the author developed an implant system and a method of restoring the entire volume of the mandible called the mandibular matrix implant system. This implant system is made of high-density porous polyethylene and is composed of an articulated wraparound geniomandibular implant and a wraparound gonial angle implant. A prejowl implant can be integrated in the system as an addition or as a replacement for a chin implant. This implant system has different sizes and projections, and it can be modified by carving to fit the requirements of most patients. Carving is done using an appropriate sizer. This implant system is indicated for use in patients with a congenitally small mandible, edentulous patients, and patients requesting facial enhancement. The mandibular matrix implant system is implanted either during a single procedure or simultaneously with a facial rejuvenation. The extended geniomandibular implant is introduced through an anterior oral sulcus incision or a submental incision. The mandibular angle implant is introduced through a retromolar incision. The posterior end of the chin implant overlaps the anterior end of the gonial implant, and screw fixation of each chin component helps to stabilize the entire system. Antibiotics, irrigation, and closure of the incisions are performed before any additional operative procedure. The complete system has been used in 13 patients; one additional patient had the complete system plus an overlapping additional left prejowl implant for correction of asymmetry. Complications were manageable; these included one mandibular angle implant displacement and one infection. The implant displacement required a reoperation to reset the implant. The infection was treated with irrigation and closed system suction; the implant was salvaged. The satisfaction of patients has been high, and the author can now solve aesthetic problems that in the past were considered unsolvable.
Chin↗
Treatment of the aging midface.
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Adipose Tissue↗
Does tumescent infiltration have a deleterious effect on undermined skin flaps?
In summary, we think that the intradermal injection of the tumescent solution with epinephrine, which produced a peau d'orange appearance of the overlying skin, resulted in superficial flap loss secondary to the vasoconstrictive property of epinephrine combined with the hydrostatic pressure of the injection in this patient within a superficial plane and flap elevation. This delayed the clearance of epinephrine from the flaps. In this case, removal of the sutures did not result in any improvement in the flap, and this maneuver was performed too late. If a peau d'orange appearance is observed after injection, we recommend waiting until the fluid has time to recirculate (15 to 30 minutes, at a minimum) and avoid immediate incising or undermining of the flap.
Anesthetics, Local↗
Buccal fat pad pedicle flap for midface augmentation.
Midface aging is characterized by soft-tissue ptosis with loss of cheek projection. Subperiosteal midface lifts may reposition the soft-tissue mounds and improve the tear trough, but may not fill the lateral cheeks in patients with significant jowls or poor bony support. Correction with alloplastic implants is helpful, but may not be accepted by many patients. During subperiosteal midface lifts, the author often excises Bichat's fat pad to decrease the jowl and to diminish face fullness. He has modified this approach and used a vascularized Bichat's fat flap to aid lateral cheek projection while still improving lower face fullness and the jowl. For the last 4 years, close to 150 patients undergoing subperiosteal midface lifts have had vascularized Bichat's fat pad flaps. The jowls were marked preoperatively. All patients had complete cheek undermining either through a buccal sulcus incision or through a crow's-foot incision, or through a muscle-sparing limited lower blepharoplasty incision. Bichat's fat pad is identified in its pocket medial to the masseter tendon. Mobilization of Bichat's fat pad is done by blunt dissection, preserving its thin fascial envelope. The "hernial saclike" pocket, excluding Stensen's duct and the buccal branches of the facial nerve, is identified and protected. Suspension is accomplished by fixation with 3-0 polydioxanone sutures either to the temporalis fascia (via the temporal incisions), to the arcus marginalis, or to the suborbicularis oculi fat pad. Fixation technique is dependent on where the fat pad is needed and the surgeon's preference. Fat pad repositioning is accomplished with a minor learning curve. The most common problems are tearing of the fat pad during fixation and temporary numbness of the long buccal nerve. Attention to leaving the capsule intact and gentle handling is essential to fixation. Nevertheless, in some patients with poor-quality fat pads, fixation is extremely difficult. Four-year results have been excellent. Further studies with magnetic resonance imaging of postoperative patients are necessary to assess longevity. Bichat's fat pad provides autologous vascularized tissue for midface fill. Placement may be lateral for cheek augmentation or medial for deep nasolabial folds. Jowl improvement also occurs with the removal of Bichat's fat pad from its pocket.
Adipose Tissue↗
Laser resurfacing as an adjunct to endoforehead lift, endofacelift, and biplanar facelift.
Laser resurfacing is a wonderful technological advance at improving the quality of aged skin. Physicians have been reluctant to perform full facial resurfacing at the time of rhytidectomy due to risk of flap slough. Newer endoscopic-assisted subperiosteal techniques allow hardy flaps without significant blood supply interruption. Since September 1995 we have performed 26 full facial resurfacings at the time of rhytidectomy or brow lift using the Coherent 5000C carbon dioxide laser. Standard settings and densities were used. Twelve patients underwent full endoscopic facelift; 5 patients, extended endoforehead lift; 8 patients, biplanar rhytidectomy; and 1 patient, standard rhytidectomy prior to immediate laser resurfacing. An additional 2 patients underwent endoscopic forehead lift and forehead resurfacing. There were three herpes infections, one in the endoscopic group, one in the biplanar group, and one in the standard rhytidectomy patient. There were 2 patients with minor skin slough in our early experience with the biplanar group. Full facial resurfacing at the time of rhytidectomy provides a one-stage rejuvenation of skin and deeper layers, and can be performed safely. However, only experienced laser practitioners should attempt resurfacing over undermined flaps.
Adult↗
Endoscopically assisted supraorbital nerve neurolysis and correction of eyebrow asymmetry.
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Adult↗
Why I prefer the endoscopic forehead lift.
The objectives of the forehead lift and the surgical principles of the open versus the endoscopic methods have been outlined. The advantages and disadvantages of each method have been described. Based on this, I state without any reservations my preference for the endoscopic forehead lift because the advantages significantly outweigh the disadvantages. Based on these and on the enthusiasm of surgeons and the high degree of patient satisfaction and acceptability, I predict that the endoscopic method with its many variations will replace the traditional open approach as a first alternative for forehead lift and upper face rejuvenation.
Adult↗
Postoperative care following CO2 laser resurfacing: avoiding pitfalls.
Facial skin resurfacing using the carbon dioxide laser has become an increasingly popular procedure. Improvements in carbon dioxide laser technology have made the procedure simpler and more reliable. However, difficulties in the postoperative period can lead to patient morbidity and physician anxiety. Common problems such as prolonged erythema, hyperpigmentation, acne, milia, dermatitis, and infection can be controlled or avoided with proper postoperative care. Less common sequela such as hypertrophic scarring and prolonged healing are often a results of errors committed in the postoperative period. The authors have performed laser resurfacing in almost 2100 patients in the last 4 years. Changes in the postoperative regimen to include no pretreatment, use of semipermeable dressings, antiviral and antibacterial prophylaxis, and early treatment with sunscreens and bleaching agents have made for a smoother recovery with more predictable results.
Antiviral Agents↗
Cervicoplasty: nonexcisional anterior approach.
The purpose of this paper is to demonstrate a technique of cevicoplasty by means of a submental incision exclusively, without removal of skin. This technique is indicated in patients with good-quality skin that has adequate capacity for contraction and redraping. The neck is approached by means of a 3- to 4-cm incision posterior to the submental crease. A thick subcutaneous flap is developed. Initial "open" dissection is continued with dissection using the endoscope. All the fat over the platysma muscle is dissected off. The dissection follows a triangle outlined by the sternocleidomastoid muscles. An insulated suction coagulator is used for hemostasis. Conservative defatting of the subcutaneous layer is done, and no suction lipectomy is used routinely. However, all the fat pad between the platysma borders and the fat pad between the mylohyoid and the digastric muscles are removed. The digastric muscles are either "shaved off" or plicated in the midline with 3-0 nylon sutures. This provides a smooth and flat contour to the submental area. Subplatysmal dissection beyond the submaxillary salivary gland is done with the aid of the endoscope. After a trial of advancement, the medial borders of the platysma are resected, and plication in the midline is performed from the level of the thyroid cartilage to the symphysis of the mandible. In most cases, a backcut on the platysma from the thyroid cartilage level in an oblique direction for about 3 to 4 cm is done to avoid secondary lateral platysma bands. If no good definition on the submental angle is obtained, an interlocked suture suspension with anchoring to the mastoid fascia is performed. The relative value of this maneuver will be discussed. The skin is allowed to redrape. Usually, after medial advancement of the platysma, an additional platysma-skin separation is needed in some segments to allow smooth contour on the surface of the skin. The suture suspension may leave minimal rippling laterally. This usually disappears in a few days. The technique described has been used for several years as an isolated procedure or as a part of a full endoscopic face lift without skin excisions. If used in the right patient, the result is comparable with that of the open excisional approach and has a high rate of satisfaction. The long-term durability remains to be seen.
Adult↗
Subperiosteal facelifting: complications and the dissatisfied patient.
As endoscopic subperiosteal lifting of the upper face is explored, it may significantly limit the indications for the open approach. However, this report is based on our combined large experience and long follow-up in open bicoronal subperiosteal lifting. The combined experience of four surgeons in four countries with an open subperiosteal approach to lifting of the upper face in 545 patients is described. The complications of the procedure, both common and rare, and techniques to avoid untoward effects are discussed. Reasons for patient dissatisfaction are addressed. Based on their evaluation of results and complications of the surgery over a 6-year period (1986-1992), we conclude that subperiosteal lifting is an effective, reliable, reproducible, and safe operation.
Face↗
Endoscopic-assisted wire removal and neurolysis.
Endoscopic-assisted surgery allows remote incision placement and provides an illuminated, magnified operative field. We have applied these principles to perform neurolysis of the zygomaticotemporal nerve and removal of a fixation wire under endoscopic control in a patient with pain and tenderness at the site of a previous zygomatic arch fracture. Endoscopic assistance aided dissection by placing the incision in a hidden, unscarred area.
Bone Wires↗
Transblepharoplasty forehead lift and upper face rejuvenation.
A complete upper face rejuvenation via blepharoplasty incisions is feasible. This technique is indicated in: (1) patients with male pattern baldness, (2) patients with a history of hair transplants, (3) patients with excessively high foreheads, (4) patients in which upper blepharoplasty is planned simultaneously with the brow lift, (5) patients with spastic frontalis syndrome, and (6) patients needing periorbital or bicularis muscle repositioning. Standard upper blepharoplasty incisions are made. Dissection is proceeded to the superior orbital rim. All the soft tissues, including the retro-orbicularis oculi fat (ROOF) pad, are elevated. A cuff of periosteum and the overlying subgaleal fascia is left. Superior dissection in the frontal area can proceed subgaleally or sub-periosteally. In the latter case, the periosteum is entered about 1.5 cm above the orbital rim. In the temporal area, dissection is done in the subgaleal plane up to 1 cm above the zygomatic arch. This dissection is accurately and safely done with the aid of the endoscope introduced through the same incision. Resection of the procerus and corrugator muscles is performed via the eyelid incision, identifying and protecting the supratrochlear and supraorbital nerves. Extra-fine-tip cautery is used for hemostasis. Initial fixation consists of suturing the ROOF pad to the periosteum of the orbital rim (two sutures). The tail of the brow is sutured to the temporal fascia (third suture). The frontotemporal flap can be stabilized in an elevated position with an external tied-over dressing, percutaneous screws, or well-supportive contouring tape, depending on the clinical situation. The eyelids are closed in a standard fashion. This operation was performed on 14 patients--12 with the assistance of the endoscope and in 2 without the endoscope. However, the endoscope has made the operation more precise. Analysis of the brow position, frontalis and corrugator activity, and the aesthetics of the upper face reveal that this operation can give results similar to other techniques with comparable morbidity, more expeditiously and with fewer scars.
Adult↗
Classification of facial rejuvenation techniques based on the subperiosteal approach and ancillary procedures.
Subperiosteal face lift is a new way of doing facial rejuvenation. There are multiple variations of technique described by several authors. Each variable introduced to the technique may be relevant to the final outcome and potential safety or complications. The most important variables are extent of dissection, combination of the subperiosteal dissection with other planes of dissection, suspension methods, and use of ancillary techniques. A systematic classification of techniques in which a lesser or greater subperiosteal dissection is made has been devised. Each technique is individualized and differentiated from seemingly alike techniques. A list of ancillary techniques is included. This classification is useful for facial evaluation and preoperative planning. A surgical proposal is made individualizing each patient's facial aesthetics rather than giving one type of operation to every patient. This classification is also useful for comparison and analysis of surgical results obtained with different techniques. It has the versatility of adding new variations and any ancillary technique adapted to the surgeon's idiosyncrasy. It can be used as a model to develop a classification of traditional face lift techniques.
Dermabrasion↗
Endoscopically assisted lipoma removal.
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Adult↗
The severely twisted nose. Treatment by separation of its components and internal cartilage splinting.
Adequate treatment of the deviated nose requires a detailed evaluation of the deformity present. A new method of component separation with internal cartilage splinting has been used with success to correct the severely deviated nose. The separation of the components allows detection and correction of all areas of cartilage deviation. The internal cartilage splinting allows long-term support and avoidance of mid-vault collapse.
Adolescent↗